Testimony presented by Ann Purchase, MS, RN, OCN to the Assembly Health Committee, January 22, 2003.
Good afternoon. My name is Ann Purchase, and I am a master’s prepared registered nurse representing the New York State Nurses Association where I am an Associate Director for the Practice and Governmental Affairs Program. On behalf of our more than 34,000 members, and the patients they serve, thank you for the opportunity to testify today on the use of marijuana for medicinal purposes. NYSNA supports A.5878 of 2002, legislation to make marijuana legally available for use to New Yorkers who have serious medical conditions that may be improved by medicinal marijuana use.
NYSNA's Board of Directors has endorsed the use of marijuana for medicinal purposes since June, 1995. My personal experience in nursing is in the specialization of oncology, and I have worked for more than 20 years with cancer patients. I have witnessed suffering as a result of chemotherapy-induced nausea and vomiting. Before I recount my personal experience with medicinal marijuana, let me provide you with reasons why we support this legislation.
First, our nursing code of Ethics embodies the nurse’s commitment to society and a commitment to change social structures that may detract or diminish health and well-being. (ANA Code of Ethics). More specifically, several of the provisions are representative of the ethical and moral obligations of all nurses. To summarize these specific provisions: nurses are committed to the patient and to the public and to collaborating with other health professionals to promote efforts determined to meet health needs; and finally, as an association, we are responsible to articulate nursing values for shaping social policy. (ANA Code of Ethics).
The benefits of medicinal marijuana have been supported by clinical research, albeit limited research, due to the restrictions in federal law. Despite the passage of New York State public health law, Article 33-A Controlled Substances Therapeutic Research Act in 1980, the law has not been effective due to barriers faced by patients. Essentially, the law required the patients to be approved by a review board, resembling a clinical trial program, and this obviously lengthens the time between requesting the use of a medication with proven results and effective treatment. Twenty-three years later, prescribers and their patients still don’t have access to a drug that has shown promise in symptomatic relief. Research supports the use of medicinal marijuana to manage pain, nausea (Tramer, Carroll, Campbell, et al, 2001), migraines, wasting syndrome associated with AIDS and cancer, muscle spasticity associated with multiple sclerosis (Dyer, O. 2001), and seizures associated with epilepsy. The palliation of symptoms is an ethical imperative for health care providers in caring for patients with advanced disease (Bagsjaw, 2002). Assembly Bill, A.5878 of 2002, supports the use of marijuana for serious, life-threatening conditions.
The individual experience of illness and disease and their resultant side effects is clearly unique. Prescribers should have all drugs demonstrating any potential clinically effective results available for their use, particularly when conventional therapies have proven ineffective.
In 1979, when I began my nursing career, there were no consistently effective anti-nausea medications, and, for this reason, the oncologists routinely wrote orders to offer Nembutal, an intramuscularly administered sleeping medication for their chemotherapy patients. Patients were exhausted by hours of persistent nausea and vomiting, and, because there were no consistently effective anti-nausea medications available, this sleeping medication was given to provide patients some temporary relief in the form of sleep. The result, however, was patients vomiting in their sleep and nurses fearing that the patients would inhale their vomit, which could have resulted in pneumonia and death. My first experience with medicinal marijuana occurred during this time. Though we knew that smoking marijuana was illegal, we were informed by our patients that smoking marijuana was the only effective medication providing them with relief after they were discharged. We had witnessed the suffering and could clearly empathize with our patients’ plight. You may ask, where did these patients obtain the marijuana, and I do not have an answer for that question, and this to me is a problem that would be solved by this bill. A.5878 of 2002 states that possession and sale or manufacture would be allowed to “certified patients”, by a “registered organization, for the purpose of lawful possession.” (A.5878, 2002). There were actually only a very small number of patients who reported they had smoked marijuana, and I believe that this would still be the case today.
Twenty years later, research has produced excellent anti-nausea medications that are effective for the majority of patients for whom I have cared. There are however, unique individuals who do not respond to these antiemetics, and it is for these patients that marijuana should be available to prescribers as an alternative to conventional medicine for refractory nausea and vomiting. Recently, I can tell you of two cancer patients I have known well; both in hospice care. Both women suffered with pain and nausea that had not been relieved by the conventionally used anti-nausea medications. One reported that the smoked marijuana was the only medication she had taken that provided her with relief. Despite her weakened condition, she was able to get out every day in a wheelchair and she was happy for every single day that she could live life to the fullest. She said she didn’t care if she was put in jail for having the marijuana, because the relief from the nausea allowed her to function. She died comfortably in her home in November. The other friend is currently trying Marinol, and when I visited with her the other day, the vomiting had subsided after the Marinol had been administered, but the nausea persisted. Nurses are able to educate patients about alternative therapies, such as dietary supplements, massage therapy, reflexology, and acupuncture, but never marijuana because it is illegal to obtain, though we would certainly like to discuss this option.
We at NYSNA recognize the opposing points of view, but let me dispel a few myths that are frequently argued by the opposition: The first myth is that marijuana is the stepping stone to drugs that could lead to serious abuse. In reference to the opiate morphine, the co-principal investigator of the 1999 expert report by the Institute of Medicine (IOM), Dr. John Benson, Jr. stated that, “fear of producing addicts through medical treatment is unfounded, primarily due to regulated distribution of approved narcotics”, and, more importantly, the “sick patients” lack of interest in abuse.” (Annals of Internal Medicine, 2001, p. 1160). He further remarked, “If marijuana were converted to a schedule II drug, with established controls on medical use, we need not expect problematic abuse by patients.” (Ibid). The New York State bill supports strictly enforced legislation that would safeguard against the abuse feared by some. My experience supports Dr. Benson, in that patients want to take just enough medication to promote their quality of life. They don’t desire extreme sedation or euphoria or the “high” associated with marijuana, but want just enough medicine to provide relief from symptoms and side effects that are interfering with their daily life.
The second myth is that smoking marijuana is not a safe delivery system. NYSNA supports anti-tobacco legislation, but, in the case of marijuana, research has never proven that there is a definitive causal link between long-term marijuana use and lung cancer. (Western Journal of Medicine 2002: www.ewjm.com).
Finally, the active ingredient in marijuana, THC, has been offered as a suitable substitute to smoked marijuana in an oral preparation manufactured as Marinol. This has been studied and approved for clinical use. Marinol is effective when a long duration of action is desired for delayed nausea and vomiting or lingering, protracted pain is apparent. But, patients frequently prefer the rapid symptom relief provided by smoking marijuana, and their ability to control the amount of inhaled drug. (Lancet, 2002, British Medical Journal, 2001).
On a broad health policy basis, the risks and benefits of marijuana use will continue to be argued. But, for patients struggling with the quality of their daily lives because of disease-related side effects, how can we wait? More controlled, multi-site research is needed; alternative delivery systems should be investigated in addition to the oral and smoked routes; but, the fact remains that the Institute of Medicine report concluded that “there are some limited circumstances in which we recommend smoking marijuana for medical purposes” (Institute of Medicine, March 17, 1999). As care providers, we are obligated by our Code of Ethics to bring about social change, to support legislation that will provide symptom relief to our seriously ill patients. We believe that A.5878 of 2002, is a bill that should be enacted. Thank you again for this opportunity. I would be happy to answer any questions you may have.
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